Healthy Babies, Healthy Children is a prevention/early intervention initiative designed to give children a better start in life. A new joint Ministry of Health and Long-Term Care (MOHLTC) and Ministry of Community and Social Services (MCSS) initiative under the direction of the Office of Integrated Services for Children, it is part of the government's investment strategy for children. Healthy Babies, Healthy Children demonstrates the government's commitment to developing an integrated system of effective services for vulnerable children. It is intended to augment and strengthen existing services for families and children.

Early childhood experiences make a critical and long-term difference in children's early development and in their health and well-being during childhood and as adults. Identifying young children (prenatal to six years of age) who are at risk of poor social, emotional, cognitive and physical health, and intervening as early as possible can improve life prospects for vulnerable children. In many cases, severe problems can be prevented if professionals and other service providers who have contact with children and families intervene early to provide supports.

Ontario has many individual examples of effective prevention and early intervention programs, but no consistent, well-developed, province-wide system of early intervention services for families and children. To develop a more consistent, effective "early warning" system, Ontario must integrate all prevention and early intervention services for children, provincially and locally. The resources of the community, including physicians, nurses, hospital staff, public health workers, social services providers and child care staff, can be mobilized and transformed into a network designed to identify problems before they become serious and require expensive, long-term interventions and to ensure children do not "fall through the cracks."

In addition, Ontario must continue to invest in early intervention programs, such as lay home visiting, that have been shown to be an effective way to identify risk, to meet the needs of high risk children and their families, to encourage healthy child development, to link to professional home visiting and to prevent costly health and social problems. For example, research on lay home visiting programs indicates that this type of service helps high risk mothers become more confident, knowledgeable parents. Children in high risk families with a lay home visitor are healthier (i.e., less likely to develop illnesses or have accidents), more likely to receive regular health care, and more likely to enjoy a safer, more stimulating home environment1.

The Healthy Babies, Healthy Children Program is designed to ensure that all Ontario families with children (prenatal to age six) who are at risk of physical, cognitive, communicative and/or psychosocial problems have access to effective, consistent early intervention services.

Using a community-wide planning process that involves all organizations and agencies that serve families and children (prenatal to age six), the Healthy Babies, Healthy Children Program will help ensure an effective system of screening and of early intervention services that makes the most effective use of available resources, puts more emphasis on prevention and early identification, builds on the strengths of families and community members, and improves outcomes for children and families. Each community network will have an early identification process for families with children (prenatal to age six).

Through the program, all families with children (prenatal to age two) will be screened and assessed, and those identified as "at risk" will be linked with appropriate services and supports. The program will also provide lay home visiting services for "high risk" families with children (prenatal to age two) who are likely to benefit from and are appropriate for that type of service, and will link all high risk families to other appropriate services.

Healthy Babies, Healthy Children is part of the revised Mandatory Health Programs and Services Guidelines for boards of health. Under the program, the Ministry of Health and Long-Term Care will allocate $10 million a year to boards of health (public health units). Boards of health will be required to lead the community implementation planning process for Healthy Babies, Healthy Children, in partnership with MCSS area offices and other organizations that serve children.

The Healthy Babies, Healthy Children Program is not a stand-alone program. It is designed to link and integrate with all other related initiatives, build on the success of other programs and services, and foster new partnerships with the volunteer, charitable, business and faith communities. The coordinated system of services provides an opportunity to assist in the prevention of child neglect and abuse.

To ensure families have access to integrated prevention/early intervention services, the Healthy Babies, Healthy Children Program must be part of MCSS area office planning initiatives and link with other organizations serving families and children.

In particular, Healthy Babies, Healthy Children must be integrated with the MCSS initiative, Making Services Work for People, which is engaging communities in local processes to reshape services for children and people with developmental disabilities. One of its objectives is to develop collaborative approaches to planning and service delivery. In implementing Making Services Work for People, communities will develop local systems of services, in which families and individuals who need services funded by MCSS as well as those funded by other ministries or levels of government will find it easier to receive coordinated services.

The MCSS document, Making Services Work for People (April 1997), describes an integrated system of prevention, early intervention and treatment services. It also talks about "reshaping" services for children and reinvesting in prevention and early intervention services for young children, so families can receive services earlier (before problems become severe) and will, therefore, rely less on services in the future.

Making Services Work for People refers specifically to the Healthy Babies, Healthy Children Program as an example of a way to integrate or network prevention and early intervention services and supports for families and children (prenatal to age six) who are at high risk. Healthy Babies, Healthy Children is part of the MCSS planning process, and local boards of health and MCSS area offices will work together to decide how best to make it fit with other initiatives.

Healthy Babies, Healthy Children will also complement other initiatives now under way, including :

the Preschool Speech and Language Services initiative, which involves health and social services and other partners in developing an effective integrated system of speech and language services for young children.

the Better Beginnings, Better Futures Program now in place in eight high-risk communities in Ontario.

Integrated Services for Northern Children serves multi-need children in rural and remote communities.

the Aboriginal Healing and Wellness Strategy is designed to promote health and well-being for families and children in Aboriginal communities.

the federally-funded Community Action Program for Children (CAPC), the Aboriginal Off-Reserve CAPC, the Canada Prenatal Nutrition Program (CPNP), the Aboriginal Off-Reserve CPNP, and the Aboriginal Head Start Program.

other public health Mandatory Health Programs and Services, such as the Reproductive Health, Sexual Health and Child Health programs.

local Child Health Networks and the Provincial Paediatric Network recommended by the Health Services Restructuring Commission.

government funding ($15 million announced in the May 1997 budget) and response to the recommendations of the Child Mortality Task Force designed to protect vulnerable children.

the Best Start Community Action for Healthy Babies Program is a six-year project (1992-98) aimed at reducing the incidence of low birthweight. The Best Start Resource Centre supports the Best Start sites and the provincial Maternal-Infant Health Promotion Network, a network of professionals from across the province.

local Infant Development Programs involved in early identification, assessment and home visiting.

All these and other programs and initiatives must be brought together to develop a system of early intervention services for children.

These Guidelines are designed to help boards of health plan and implement the Healthy Babies, Healthy Children Program. They will be supplemented by other documents that will provide more details and information on program requirements and best practices, including :

The following goal and objectives are taken from the draft Public Health Mandatory Health Programs and Services Guidelines. These public health guidelines, which include the legal requirements of boards of health, are currently being revised and, once approved by the Ministry of Health and Long-Term Care, will be distributed to boards of health.

Goal

To promote optimal physical, cognitive, communicative, and psychosocial development in children who are at risk.

Objectives

Increase access to and use of needs-based services and supports for children who are at risk of poor physical, cognitive, communicative, and psychosocial development, and their families.

Increase effective parenting ability in high risk families.

Increase the proportion of high risk children achieving appropriate developmental milestones.

The attainment of these objectives is linked to the Reproductive Health and Child Health objectives in the Mandatory Health Programs and Services Guidelines.

The Healthy Babies, Healthy Children Program consists of five components :

Develop and maintain a network of health and social service providers to ensure that families with children (prenatal to age six) who are at risk of physical, cognitive, communicative and/or psychosocial problems have access to a range of prevention and early intervention services.

Link families with children (prenatal to age six) who are at risk of physical, cognitive, communicative and/or psychosocial problems to appropriate supports and services in the community.

Screening prenatally and at birth to identify those at risk who will be further assessed to identify the high risk families with children.

Ensure that high risk families with children (prenatal to age two) who would benefit from lay home visiting have access to this service, either by providing it directly or purchasing this service from existing home visiting programs that can meet the program's requirements.

Identify a case manager from the most appropriate agency for all high risk families.

The intended population for the Healthy Babies, Healthy Children Program is all families with children prenatal to age six who are at risk of physical, cognitive, communicative and/or psychosocial problems.

There are children and families in Ontario who are dealing with stresses or risk factors that could have a negative effect on a child's ability to achieve optimal physical, cognitive, communicative, and psychosocial development and, in a universal screening program, would be assessed as "at risk." The stresses that could put a family at risk would include :

economic and social risk factors, such as lack of social support, social, geographical or cultural isolation, low level of education, sole support parenting, maternal age at the birth of the child (e.g., adolescent mothers), low income;

infant health risks, such as low birthweight, congenital defects and/or syndromes, parent(s) with a physical or development disability;

parent health risks, such as parent(s) with a psychiatric illness, parent(s) with substance abuse problems, parent(s) with dual diagnosis (e.g., psychiatric disorder and substance abuse), a history of domestic violence and abuse.

A brief assessment of families that may be at risk would identify that :

some families either have the strengths, resources and resilience to manage on their own or have problems that can be addressed by linkage to services in the community. For example, newborns identified with developmental disabilities will be (or may have already been) referred to infant development programs;

other families need more in-depth assessment to better determine their level of risk and identify appropriate interventions and supports;

The in-depth assessment would determine the level of risk and identify :

families who are not at high risk and can be linked with services and supports in the community;

those families that are high risk and in need of specific, focused interventions and support. Of these, some are appropriate for and would benefit from lay home visiting. Studies estimate this is approximately six per cent of the birth cohort for the province.

High risk families, including those already receiving services, are the intended population for the lay home visiting component of Healthy Babies, Healthy Children, but not all high risk families will be appropriate for lay home visiting. Lay home visiting is a prevention and early intervention initiative, designed to prevent problems from occurring, not a treatment program. It is up to each Healthy Babies, Healthy Children program to make the most effective use of its resources. The public health nurse or someone with equivalent skills conducting the assessment will identify which high risk families are likely to benefit from and be appropriate for lay home visiting, and those who will be better served through other programs and initiatives.

In assessing whether a high risk family will benefit from and be appropriate for lay home visiting, the public health nurse, or someone with equivalent skills, conducting the assessment will consider several different factors, including :

do any of the services the family receives now provide parenting support? is it enough? if not, is there a way to augment it?

given the other problems, is the family able/ready at this time to focus on parenting issues and benefit from lay home visiting?

is home visiting the most appropriate way to meet this family's needs or would other services be preferable?

will this be the most effective use of resources, or is there a more cost-effective way to support the family?

is the family willing to have a home visitor and willing to participate in the program?

are there any factors in the family situation that would limit the ability of the lay home visitor to function effectively? For example, is the family in crisis?

is the child at any immediate risk? Does the family require intervention from the Children's Aid Society?

what is the level of need?

These factors should not be used to exclude families but to help in assessing readiness, including appropriate timing.

Studies estimate that approximately six per cent of families will be high risk and appropriate for the lay home visiting component of the Program. However, all families identified as "at risk" or "high risk" will be linked to the services they need.

Screening and assessment tools for the Healthy Babies, Healthy Children Program will be selected or developed to clearly define "at risk" and "high risk" and help communities identify families who are "at risk" and "high risk."

To receive ongoing funding under the Healthy Babies, Healthy Children Program, boards of health must submit an implementation plan. MOHLTC and MCSS will provide a template for the implementation plans/submissions. Each year, boards of health will also be asked to submit detailed operational plans to the Public Health Branch of the Ministry of Health and Long-Term Care.

To ensure the planning for the Healthy Babies, Healthy Children Program is collaborative, builds on the resources of the community and is part of a network of prevention and early intervention services for children (prenatal to age six), both the MCSS area office and the board of health must agree on the content and approve the local plan. In rare situations where no agreement can be reached, direction will be provided through the Office of Integrated Services for Children. In addition, implementation plans will be reviewed by an interministry committee to ensure that they meet the following criteria :

positioned to build a system of prenatal, postnatal and infant prevention and early intervention services;

linked to the MCSS area office planning for "Making Services Work For People.";

multi-sectoral and uses the resources of the community;

build on "best practices";

will result in increased prenatal and at-birth screening/assessment of psychosocial and environmental risk factors;

will reduce duplication in assessments and waiting lists;

will result in better linking at-risk expectant parents, children (prenatal to age two) and their families with appropriate services and supports;

linked with the pre-school speech and language system;

avoid duplication of lay home-visiting services;

address the development of protocols/agreements with agencies to ensure a system of prenatal, postnatal and infant prevention and intervention services is established;

culturally appropriate and take into consideration the unique needs of communities, such as the Aboriginal community;

consider the needs of francophone families in areas designated to provide French language services;

support the front-line service providers of the health and social service sectors in their responsibilities and efforts to reduce risks to children;

In planning for Healthy Babies, Healthy Children, boards of health in partnership with MCSS area offices must focus on two related components :

developing a network of health and social service providers who will provide a range of prevention and early intervention services;

developing direct services (i.e., screening and assessment services, lay home visiting services, referrals to other services) that are part of the program.

Although the primary responsibility for program planning and implementing Healthy Babies, Healthy Children rests with the boards of health in partnership with MCSS area offices a broad range of organizations involved in children's services must be part of the planning process. The implementation planning group should reflect the range of services and the communities to be served. The planning process should fit with the overall plan of Making Services Work for People.

Planning Implications: The boards of health should use the planning process itself to help develop the network of service providers and early intervention services that is an integral part of the Healthy Babies, Healthy Children Program. Many communities already have planning groups organized to co-ordinate or integrate children's services, so a new planning structure may not be required to plan the Healthy Babies, Healthy Children Program. We recognize that not all communities have this range of services and providers, however, wherever possible the implementation planning group should include :

parent associations and interest groups with parents who have direct experience in accessing services to prevent developmental problems in their children (for example, in communities where there is a Better Beginnings, Better Futures Program, Aboriginal Head Start Program or Best Start Program, these parents should participate in planning the Healthy Babies, Healthy Children Program);

professionals and other service providers who have contact with expectant parents and young children (prenatal to age six), such as : family physicians, paediatricians, nurses, social workers, hospital birthing unit staff, midwives, early childhood educators, speech-language pathologists, psychologists, child psychiatrists, child care staff, children's aid society workers, family resource centre staff, infant development program staff, children's treatment centre staff, providers of home-visiting services, recreation staff, community health centre staff;

Aboriginal child and family services, and Aboriginal child care centres;

representatives from charitable foundations/organizations, faith communities and the business sector;

representatives from the governing bodies responsible for planning, funding or delivering services to children and families (e.g., municipalities, school boards, hospital boards and service organizations);

representatives from the child care sector;

representatives from the community speech and language committee;

district health councils.

To encourage groups that have historically been excluded from service and program implementation planning to become involved and participate, organizers may have to be innovative. In communities with significant Aboriginal populations, boards of health will use innovative strategies in planning and implementing the Healthy Babies, Healthy Children Program, which will involve and serve Aboriginal families at risk.

The plan to implement the Healthy Babies, Healthy Children Program must include an analysis of the community's current capacities. An inventory of services is also a requirement of the MCSS Making Services Work for People initiative. The inventory of services forms the basis for linking families and children at risk to appropriate services and supports. It also identifies gaps in service, waiting list issues, program overlap and case co-ordination issues that the community may want to address.

In a number of communities, organizations have already developed service inventories and systems to collect and update local program and service information. The Healthy Babies, Healthy Children inventory of services should not duplicate these efforts. Communities are being asked to develop one inventory of services, and should build on any work that has already been done.

Planning Implications: If the development of a service inventory is required, the implementation planning committee must collect basic information on the prevention/early interventions services for children available in the community, including program descriptions, admission criteria and catchment areas. This includes :

The Healthy Babies, Healthy Children Program includes a screening and assessment process designed to ensure that all families and children "at risk" are identified and referred to appropriate services, and to identify the proportion of "high risk" families and children who could benefit from lay home visiting. The screening and assessment process involves three steps :

an initial screen, which will likely be done at the hospital at the time of birth or prenatally by physicians, midwives or nurses;

a brief assessment on the portion of families deemed "at risk," to be conducted by public health staff or an agency designated by public health2;

an in-depth, home assessment on the portion of families who may be "high risk," which will be conducted by public health staff or an agency designated by public health3.

2 Where an agency in the community is already responsible for a central assessment process, public health can purchase the assessment service from that agency.

3 Where an agency in the community is already providing home assessments, public health can purchase the assessment services from that agency.

In-home assessments will be provided in very complex situations and/or where the level of risk is unclear. This comprehensive home assessment will determine the level of risk and help the public health nurse doing the assessment link the expectant parent or family and newborn with the appropriate services and supports in the community. As a result of this assessment, the public health nurse may develop a lay home-visiting plan for the child and family and/or arrange for other services and supports. This may include identifying an appropriate case manager, who would usually be from the agency with the greatest contact with the child and family.

It should be noted that the formal screening and assessment process is not the only means to enter the Healthy Babies, Healthy Children Program. Service providers may at any time refer expectant parents and young infants to boards of health4. The referral may be made to clarify risk, to ensure follow-up to link the family with appropriate services, or to determine whether lay home-visiting would benefit the child and family. In addition, families with children up to age two can self-identify, or they can be referred directly to the program by a physician or other health or social service provider.

4 Providers can also link families to other Mandatory Health Programs and Services, such as Child Health and Reproductive Health.

The Office of Integrated Services for Children will recommend an early identification process designed to help parents and care providers recognize conditions and factors that put children at risk. Early identification is particularly designed to "catch" children up to age six, who are missed in the prenatal/at birth screening process or whose situation changes after that initial assessment.

The Office of Integrated Services for Children has established an expert panel to select/recommend a screening tool and an assessment instrument for the Healthy Babies, Healthy Children Program. These common tools will be used across the province. Communities can choose to add elements to the screening and assessment tools to meet their needs, but are required to use the basic tools.

To ensure the screening tools are used consistently, the Ministries of Health and Long-Term Care and Community and Social Services will be working with the appropriate professional colleges and associations to disseminate tools and encourage their members to use screening in their practice.

Planning Implications: The plan to implement the Healthy Babies, Healthy Children Program must include a protocol for the screening and assessment process, including :

an agreement between providers, such as the public health unit and hospitals, physicians, midwives, nurses and prenatal clinics to administer the screening with all pregnant women or those who have just given birth;

an agreement between the providers, as listed above, on agreed referral protocols to both public health and to other community agencies;

when public health designates another agency to provide the brief assessment and/or the in-depth assessment, an agreement between the public health unit and that agency to provide the assessment service.

Lay home visitors are parents from the community who can relate to/communicate with the families they visit and who will be trained through this program in child development and how to support families. They work with families to build on their strengths, develop their parenting skills, help them connect with resources in the community, and promote healthy babies through safety, growth and learning. They are supported/supervised by a public health nurse who has skills in adult education, communication, problem-solving, conflict resolution and other fields, as determined by community needs.

A trained and supervised lay home visitor may provide a range of services, which will be identified in the detailed training materials. For example, they may share information about healthy child development and how to provide a safe, secure and nurturing environment, give the family opportunities to learn about behavior management and living skills, and demonstrate games and activities to encourage growth and learning. With support from a public health nurse or someone with equivalent skills, the home visitor may also provide information on feeding, family planning and general health, and help the family link with appropriate supports and services in the community.

Lay home visiting, under the supervision of a public health nurse or someone with equivalent skills, can begin during pregnancy or when an infant has been identified as at high risk of a developmental problem. Healthy Babies, Healthy Children will build on current home-visiting services in the community. To avoid duplication, boards of health may decide to contract with an agency that currently provides lay home-visiting services.

To help boards of health develop their lay home visiting programs, Invest in Kids Foundation has agreed to provide recommendations on recruitment and selection guidelines, salary ranges, job descriptions, interview questions, training program/materials. The Ministries of Health and Long-Term Care and Community and Social Services will provide the results of a key informant survey of Ontario home visiting programs for families of children up to age six. In September 1997, the ministries will provide information to help boards of health recruit lay home visitors as well as information on lay home visitor training that will establish a minimum standard for the province.

Planning Implications: The local plan must include methods to :

identify existing home visiting programs in the community and describe how the Healthy Babies, Healthy Children Program will co-ordinate with them;

develop agreements between the board of health and any agency designated to provide some or all of the home visiting component of Healthy Babies, Healthy Children;

recruit home visitor(s) appropriate for the Healthy Babies, Healthy Children program by October 1997 to assure the appropriate training prior to implementation;

describe the policy for the initial and on-going lay home visitor training required to address emerging program needs and ensure lay home visitors maintain their skills;

describe how the board of health will ensure that lay home visiting programs meet minimum standards;

establish a plan for the on-going process of supervising lay home visitors;

refer to children's aid society for children who require protection.

Communities are encouraged to be creative in how they use their resources to ensure that families receive the intensity of service they need to benefit. On its own and at the current level of funding, the home visiting component of Healthy Babies, Healthy Children is expected to provide an average of 13 visits per family over two years. However, communities can combine this funding with other resources to provide more intense visiting services or use other programs, such as Nobody's Perfect, to augment the Healthy Babies, Healthy Children home visiting. The community will have to develop transition plans for families and older children.

In communities where lay home-visiting programs currently exist and are meeting the needs of high risk families and children (prenatal to age two), boards of health may use the Healthy Babies, Healthy Children funding to enhance programs for high risk families with children (prenatal to age two) or provide home visits for high risk families with children beyond two years of age.

At each stage of the screening and assessment process, boards of health will identify families who should be linked with other services - either in addition to or as an alternative to the lay home visiting service provided through Healthy Babies, Healthy Children. All families who are identified as "at risk" or "high risk" will be linked with appropriate services.

Using the network of service providers and the service inventory, boards of health will identify appropriate agencies and organizations. The linkages will vary depending on the community and its capabilities. Each community will likely have its own issues or service gaps that will have to be addressed. The process of linking and following families through the network of services and service providers will be ongoing, and will be developed and refined over time.

Planning implications: In preparing the plan to implement Healthy Babies, Healthy Children, boards of health and MCSS area offices should :

identify the process that will be used to identify case managers, to link and follow families, and to ensure that no one "slips through the cracks";

identify any issues in the community that may affect the ability to link families to appropriate services and how they will be resolved;

develop an agreement between the public health unit and community organizations involved in children's services to accept families who have been identified, through brief assessment and in-home assessment, as potentially able to benefit from their services;

clarify the role the Healthy Babies, Healthy Children Program will continue to play with families who are linked with other services;

ensure protocols are in place between the boards of health and the Children's Aid Society for children who require protection.

All Healthy Babies, Healthy Children Programs will be required to participate in a process of monitoring and evaluation. Evaluation is a critical component of this program. An ongoing community committee that includes the board of health, MCSS area office, and key stakeholders should be formed to ensure accountability.

The evaluation of the Healthy Babies, Healthy Children Program will focus on established social and health outcomes, which will be provided in a supplementary document. In addition, boards of health have a contract regarding the mandate of services and financial accountability. The Public Health Branch of the Ministry of Health and Long-Term Care will establish data requirements. More information on monitoring and evaluation will be provided.